What did you expect?

We have become obligate avoiders, dwellers in the middle of the field well away from boundaries –the just-right-baby-bears of the Goldilocks tale. We seek to protect ourselves from edges, no matter how pervasive, how common, how important they may be. It was for a very good reason that the American folk hero, John Wayne, felt he had to remind us that ‘Courage is being scared to death… and saddling up anyway.’

Most of us seek to insulate ourselves from every extreme: we read about our lives from the safety of a middle page while dreaming of the youth in early chapters –as if there were no beginning or conclusion to the book. I suppose it reads as well in the center as at either end, but that misses the point; the book is a story –our story- and to ignore the epilogue or, for that matter, the introduction is to miss the context in which it is written -the gestalt.

The end of life, is an example –until recent times, most people in Western civilizations died where they lived: in their own homes. Family and friends were usually there to provide comfort and support; it was not treated as an event that necessitated separation, but rather as a communal passage –something that invited witness and provided solace for all involved.  Dying, especially of advanced age, was not something to be hidden away or delegated to strangers, however skilled. Death was visible and inevitable; death was a known, if unwelcome guest in each home.

Birth, the beginning of the story, has also had a somewhat chequered history. It, too, was once relegated to the home, but with sometimes unfavourable results for both mother and baby. This led to it being assigned to areas –or assistants- with more training and facilities in case unexpected -or anticipated- problems arose. And while, as an obstetrician, I feel more comfortable in an institutional setting, there is no reason why a well-trained midwife should not be able to pick and choose the appropriate venue for the birth depending upon her assessment of the risk involved. And there is no reason, either, why family or friends should not be able to witness and support the event.

I was surprised, therefore, to come across an article in the BBC news that treated as, well, unusual, the idea of a mother’s children being present to witness the birth: http://www.bbc.com/news/uk-37020059

Clearly, some vetting might be required in terms of the children’s age and behaviour, but as long as they are prepared beforehand, and there is someone else in the room who could supervise and help them understand what is happening, I think it could be a positive experience. Birth and Death should be presented as they are: natural events –not secrets whispered behind closed doors.

*

I kind of suspected birth was no secret to Loretta’s kids. A third-time mother of six and  nine-year-old daughters, she brought them to every antenatal visit. I asked her one day while her older daughter played doctor with my stethoscope, how she managed to get them out of school each time.

She pointed to her watch. “Ever notice that I always book my appointments around noon?”

I nodded. We’d often joked about our stomachs rumbling each time we met. “But they don’t mind leaving their friends to come here?”

“McDonald’s,” she said and then shrugged. “It’s their reward for agreeing to come with me.” She was silent for a moment and then stared at me, her eyes twinkling. “Don’t look at me like that, doctor. Remember Bill Clinton?”

I nodded, puzzled by the non sequitur.

“I never inhale,” she whispered conspiratorially.

The girls were always on their best behaviour in the examining room –full of questions and wanting to try my equipment on themselves. I suspect that the visits sometimes even cut into McDonald time, but they seldom complained –they were much too curious about the growing baby. They never seemed to tire of asking me how much it weighed, and whether it could hear them through their mother’s tummy –apparently they would sing to it at home. The moment they both waited for, however, was when I would place the Doppler device on the uterine wall so they could hear the heart. Janice, the older one, would even time it with her watch to make sure my device was counting correctly. They were both as involved in the pregnancy as their mother.

One day, towards the end of the pregnancy, Loretta phoned me. “I’ve been thinking of letting my girls see the birth,” she said. I could hear a little hesitancy in her words as she spoke. “Will the hospital allow that? My mother will make sure they don’t get in the way,” she added, almost too quickly.

I smiled into the phone –I’d been expecting her to ask. “As long as they know what to expect Loretta. There’s sometimes a lot of… well, yelling as you push… and a lot of blood –especially when the placenta comes out.” I paused for a second. “They have to be told that none of that means there is anything wrong. I wouldn’t want them to become scared.”

She chuckled into her phone. “They watch deliveries all the time now on YouTube, doctor –complicated ones, scary ones, and even ones that end up in Caesarian Sections. I think they’ll be all right.”

“Then it’s fine with me.” I reminded her that I may not be on call when she delivered, but she merely laughed.

“You didn’t make it for the first two either…”

*

Obstetrical practice nowadays is a hectic melange of joy and crisis, each delivery unique and exhilarating to be sure, and yet strangely merged into the one a few minutes before and blended into the one a few minutes later when on call at the hospital. So I have to admit that I was pleasantly surprised one evening as I was rushing to yet another delivery further down the hall when a nurse informed me that Loretta had just been admitted in labour.

“She’s almost fully dilated and it’s her third baby; she won’t be long…” she yelled as I ran past her to the accompaniment of screams from the room where I was originally heading.

Obstetrics is sometimes an exercise in ad hoc triage, and the screams were becoming louder and more compelling from that room, so I had little choice in the matter. I arrived just in time to exchange the mother’s for the baby’s screams, and allow a placenta to jump suddenly into my lap while she snuggled her precious baby against her abdomen.

In the warmth of smiles and congratulations that followed, I almost forgot about Loretta until the nurse’s face appeared in the door. “They want you in Room 8, doctor,” she said, almost casually.

I removed the placenta from my lap and stood up ready to run from the room.

The nurse shook her head sternly. “Better not show up like that,” she said, pointing to my gown. “You’ll scare the girls…”

I grinned sheepishly from behind my mask. I’d forgotten about the girls.

Loretta’s room was strangely calm when I arrived. Everybody was smiling, the baby already snuggled skin to skin on Loretta’s abdomen, and the girls were standing beside their mother enthralled and staring wide-eyed at the crying baby.

Maria, another nurse, who’d been with Loretta since her admission, was just removing her gloves after making sure the newly-delivered placenta was in its little metal bowl. Even though trained as midwives, the obstetrical nurses rarely get a chance to exhibit their skills except at times like this, and she was smiling from ear to ear. Things had obviously gone well.

“Congratulations, Loretta,” I said and immediately blushed. “Looks like I missed number three as well. I’m sorry…”

“Don’t be sorry, doctor. Maria did a fabulous job.”

Maria glanced at Janice who hadn’t even noticed that I’d finally come into the room then focussed her attention on me. “Actually, I was a bit rusty,” she said with a mischievous smile and winked at me. “Janice kept reminding me what to do next…”

Janice turned her head and stared at me. “Maria did a good job,” she said approvingly, “But she dropped the placenta,” she added, her face turning serious like a teacher unwilling to overlook a mistake. “I told her it’d be slippery…”

 

Doctor on Call

“Are you going to be there to deliver me, Doctor?” It is a question I hear each time I see a new obstetrical patient and one for which I have to admit I am never prepared. After all, the patient has come to see me because either they or the referring doctor feel that I have something to offer. And however mistaken they may be, a choice was still made. Expectations engendered.  After doing whatever research you felt was necessary for your choice, you do not choose a red car and expect to drive home in a blue one, even if it’s just as good.

So the answer to that question is a difficult one for both parties: she bonds with me, but I also bond with her. And given the exigencies of a call schedule, there is bound to be a disconnect. No matter the desire, I simply will not end up delivering all of my patients; the odds are just not there. The patient has to decide if she wants to invest in a long-term relationship of trust and respect with someone who is  possibly going to abandon her when she really needs it: at the apotheosis of the entire process.

But nowadays, no matter who she chooses -family doctor, midwife, obstetrician- they are all on call schedules. No one can be available all the time. In my particular practice there are seven other obstetricians, so the chances are only one in eight that I’ll be the one she’ll see on that special occasion. I’ve tried answering their question like that, but the look on their faces when presented with the odds have taught me that it’s helpful to alter the perspective somewhat: same answer, different context.

Pregnancy is a long road, and like any journey, it’s important to be well-informed along the way about what to expect and what to avoid. Guide books do this, don’t they? That’s one of the reasons we consult them; and the more relevant and assimilable information they offer, the better they are. The trip is almost as important as the destination. If the one is enjoyable, if we know a little bit more about the places we pass, it certainly doesn’t detract from where we hope to end up. Reassurance and advice along the way may not shorten the journey, but give us confidence we’ve taken the correct route.

And in my centre, whoever is on call, lives in the hospital for 24 hours, so if my patient were to present herself to the Delivery Room with an unanticipated problem in the middle of the night, or have some worrisome symptoms that need investigation after office hours -and isn’t that when they usually occur?- there is always a specialist available. No need to worry if their own doctor can get through the rush hour traffic in time, or whether his phone is turned on; someone is always there to help, no matter how grave or trivial the problem. And I trust my colleagues’ judgments; I suspect -I hope- this is not unique. In fact many of them were my residents in past years, so I know how they perform in emergency situations. I think sharing this with my patients helps to alleviate at least some of their frustration at a system that seems to franchise obstetrical services to strangers.

In fact, when I am on call and delivering a colleague’s patient, I sense an understanding, an acceptance of the delegation of responsibility to someone else and I try to be mindful of the fearful joy attendant upon the delivery they have so long anticipated. I try to be respectful of their expectations, their customs, and yes, even their idiosyncrasies. God knows I have enough of my own.

I try, in other words, to show them that it isn’t an abandonment, an uncaring assignment of their health to a surrogate simply because I choose not to be available all the time. But I suspect they know this. Neither the doctor nor the midwife, is the pregnancy. And neither of us is the delivery. We -I- am merely the person riding shotgun on the stagecoach making sure that the strong-box makes it safely to Dodge… Where did that metaphor come from..?